Running a Neurofeedback Practice

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General Thoughts

Look at the Brain

I started doing EEG in 1991 and ran a practice for 10 years in Atlanta with 4 offices. We worked with whatever walked in the door. Some had gotten diagnosed–with ADHD, fibromyalgia, mood disorders, etc.–many wanted to avoid that long journey down the endless road of “pathology”.

When they would ask if they should bring their diagnostic tests, etc. I always told them not to bother. All we cared about was what was bothering them–not what it was called. I told them we weren’t doctors or therapists. We were personal trainers for their brains.

People came who were depressed or anxious, angry or uncontrolled, unfocused, struggling to sleep, experiencing pain or fatigue, and we paid attention to what they wanted to change. Some wanted to become “peak” performers. Some had been told by the experts that there was no hope of further improvement. We didn’t talk about their “disorders” and we didn’t promise to “heal” them. We didn’t worry about what “caused” the problem We simply trained what the brain showed us and tracked how they felt, acted, performed, learned and experienced themselves. We demonstrated to ourselves and to those we worked with that exercising the brain to change its “energy habits”, could produce lasting results in their lives without labeling, without medicating.

I trained hundreds of clients over 10 years and supervised the work with hundreds more. The worst results we got were “no change” when we felt strongly that everything supported a change. We had some sessions, though very few, where a client had a negative response to training (became irritable or had a headache or rebounded emotionally or returned to where they had been before training), but they were quite rare and lasted normally only a couple hours, if that, before they faded away.

I was fortunate enough to begin learning with Joel Lubar, who was a strong proponent of looking at the activation patterns in the brain before training them. That got me started on the road that ended up leading to the TLC Assessment, which, as you have perhaps read here lately, can provide you with a tremendous amount of accurate information about how the brain has organized itself and allow you to focus on patterns which are likely to underlie the issues a client wishes to train. That made a huge difference in the success of my interventions, because I was only guiding brains toward changing in ways that would be expected to result in positive outcomes.

I was also fortunate to learn from Sue Othmer, who stressed the importance of watching the client and following the client’s experience, rather than trying to make changes on a graph. When clients don’t like a particular training, mine know that they are empowered to stop the session in a second. If they do so, negative responses are fairly rare–and as I said above, rarely last an hour.

Peak Performance

Many people who look at starting neurofeedback come with a problem set (or symptom constellation) they would like to fix. Your listing of “stop worrying and thinking so much”, “not make compulsive decisions”, etc. could fit into that kind of problem list, and brain training can help with all of those, if you train the right thing.

Many others come looking for “peak performance” and “personal growth”, and brain training can help with those as well. In fact, it has been argued that all neurofeedback is peak performance training (if focused on the right issues for each individual).

Peak states in our field are often defined in the areas of synchrony training among specific sites and alpha theta training (generally after doing some other work first). But lots of people have existing patterns in their EEG’s that make it extremely difficult for them to do either of these kinds of training until other issues have been cleared.

Around 20 years ago, when I started adding peak performance to my work with ADHD and mood issues, etc., I thought it would be really cool to work with clients who really had no problems. And since I was working hard on developing my assessment at that time, I gathered data from their brains, so I could see what really functional brains looked like. Not surprisingly, when I looked at the EEGs I found many of the same patterns I was accustomed to training in people who DID have diagnoses. I still remember the first guy who came to me–a CPA who was chief financial officer for a mid-sized corporation. He had no problems whatsoever–was already a peak performer–and only wanted to be able to do more, do it faster and better. When I saw his brain patterns, I asked him, “so you really don’t experience any anxiety it all?” “Anxiety!?” he answered. “It’s with me every minute of every day–has been since I was a little kid.” But there was nothing “wrong” with him. I agreed. But we started working on the patterns that indicated anxiety, and he experienced pretty profound changes in his performance–and especially the responses of his wife and kids–before we ever started doing the “peak performance” protocols.

Finally, a word to the wise about your target population. Many people who plan to work with “peak performance” clients believe that they can skip the assessment process, because, after all, these folks obviously don’t have anything wrong with them. Not true. Anything you do in the brain to move it into a more flexible and stable state, which is the main goal of NF, will improve the client’s performance. Every one of the “peak performance” clients I ever worked with, people who had “no problems” when they came in, when we looked at their assessments, and I asked them about things I saw there (anxiety patterns, inattention patterns, etc.) admitted that, yes, those things were present. When we trained them, performance got better. So be aware that many peak performance clients have the same issues that many “clinical” clients have–they just don’t want to cop to it. There is assuredly a set of trainings you can do that will strengthen peak states in a client, but I believe there is a great benefit to getting the brain balanced first.

Train Yourself First

I strongly recommend that anyone working with EEG begin with an assessment of your current brain patterns and develop a training plan based on those: look at what you want to change before you start trying to change it. You will be far from the first person on this list to take the step on your own and begin preparing to train you own brain. It’s where I started 21 years ago. I’m a great believer that most of us learn skills and techniques most quickly and effectively by actually DOING the thing we want to learn. In the courses I’ve been teaching since 2001, I’ve come to separate participants into two major groups: there are those who go home and DO neurofeedback, a step at a time, stumble a little, make a few mistakes, but overcome the resistance of fear and begin practicing; and there are those who go home and start looking for the “best book” on neurofeedback or magazine articles, or a study group or ANYTHING that will help them avoid maybe making a mistake. Most of the first group end up working with the process–some for many years–and make major changes in their own lives and those of others who work with them. Not ONE of the second group (to my knowledge) has EVER gone on to do a single training session, though they can write essays on a dozen theories as to how it should be done.

Certainly there are plenty of people who have clearly dysfunctional patterns of behavior or limitations in attention and/or control. Heck, with the psychiatric diagnostic manual (DSM IV) running to 886 pages–double the number in 1980 for DSM III), it’s pretty hard to be mentally healthy these days if you go looking for a diagnosis. One of the key psychiatrists who worked in the version III–which only had 494 pages!–Robert Spitzer later said he regretted his part in the process, because it “led to the medicalization of 20-30 percent of the population who may not have had any serious mental problems!” Trying to stay out of that mill is a perfectly valid way to approach self-improvement.

So let’s leave to the side for now the question of whether you have anything “wrong” with you or not. Mental health diagnoses are essentially descriptions of symptoms. What is Attention Deficit Disorder? It means you have trouble paying attention. Why? What’s the underlying issue? Nobody knows. So my preference is to skip the diagnoses and ask the client what they would like to change: what would you like to be able to do faster, better or more easily? Everybody has a few of those, even the sanest person I know (me).

Gather your own assessment first, and do maybe 10 sessions just on your own head first. HEG: the sky’s the limit; friends, family, folks walking by on the street. No assessment, no setup, no clean-up, 15-20 minutes 3 times a week. Start that with anyone who wishes. It will help you get started with BioExplorer, and sometimes you can get some very impressive early responses. Gather a few assessments and get plans for a few friends who are interested and start them on HEG. After your 10 sessions, when you are pretty comfortable with BE and the designs and reading the plan, then begin with interested others.

Neurofeedback as Service, not Product

In an information-driven society like ours, whoever has the bigger marketing budget wins–most the time. But taking the budgets of just a few of the major multinational drug companies, the amount of advertising and packaging they do dwarfs what “mom-and-pop stores” can do. NF is a service business–not a product. It’s one-on-one, and though you can arrange ways to be seeing 2 or 3 clients at the same time, there still are no economies of scale. Nobody profits from NF financially–not like a drug company profits.

The point is not that it’s necessary to show that NF works–often as well or better than the chemical approach. We know it works to the extent that–as far back as 1994, I kept 4 offices busy in my Atlanta practice pretty much completely on word-of-mouth referrals. Twice in the first couple years, I contacted psychologists to make a presentation to them about NF back when I believed that “published evidence” would open professional eyes. Neither of them would see me. One, whom I knew from previous work, told me he couldn’t refer anyone to me because his reputation would be damaged–before he even knew a thing about NF. But both of them referred their own kids to me, and both of them improved significantly with the training. I didn’t get any word-of-mouth from them.

Neurofeedback as Religion

I consider there are two common disorders (if I may wax psychological for a moment) that afflict many in this field. The first is “neurofeedback as religion” disorder: Whoever I learned from is my god; I don’t ask questions, I do what they say. The second is “one more piece of equipment will make it all work out” disorder: You can never have enough platforms and/or software packages. Try to avoid these two perspectives.

Brain Training, not Mind Training

I stress to all clients that we are NOT training the “mind”. We are training the brain. When the client’s conscious mind intervenes (as is its wont), it muddles the feedback reaching the brain. So in all training I tell the client don’t think, don’t try, don’t judge. Just pay attention to what is happening (visual or audio feedback).

When a client “thinks”, he is inside his own head. Judging and trying are the same. When you observe and attend without trying, the information goes straight through to the brain, and the brain is able to better connect what it is doing with what is happening. I don’t usually tell the client what I want in terms of feedback, though the design often does. If I’m using music feedback, I tell the client “every once in a while you’ll hear a chime, and know that’s really good. But don’t try to make the chime play, because you can’t.” That helps the brain decide which is the more desirable direction for it to move.

Negative Responses to Training

I have certainly seen negative responses from NF–some pretty bad. But in every single one of those cases, when I tracked back, I found a trainer who was simply going into the brain blind and trying this or that or something else based on some recipe (often poorly understood). A client might, for example, show externally a rather flat and depressed affect. In some systems, that would lead us to say, okay, we need to train up fast activity on the left side of the brain. But anyone who has taken Level 2 training on the TLC Assessment knows that such a client could well have a left-sided disconnect, resulting from severe neglect and lack of nurturing early in life. Depression and flat emotional reactions would be common with that pattern. The brain would show extremely HIGH levels of beta and high-beta on the left side (particularly at T3). What will be the result of training for MORE beta in that kind of brain? Not positive!

In many of those negative response cases, there was also a trainer in the background who believed that, since his recipe said “do X”, he should keep doing it, no matter what the client’s response. The client during or after a session reported negative results, but the trainer said, “good medicine tastes bad” and continued training what the brain was rejecting.

In short, a little common sense and knowledge can avoid most, if not all, negative reactions.

I was recently thinking of taking a course in driving and getting my driver’s license, but then I talked to a taxi driver, and he warned me to stay on my bicycle, because it was possible to do extreme damage driving a car. Now I’m having second thoughts about getting my license, and I guess I’ll just keep calling a cab whenever I need to go somewhere outside the range of my bike.

I would ask your taxi driver how many cases has HE had where he caused severe damage to a client. Or has he just “heard” that it’s possible. There are many on this list who have no more clinical training than you (myself included) who have worked with very difficult situations and gotten very good results. The client does the work–not you. You are a coach, not a player on the field, unless you have the electrodes on your own head (which you should absolutely do!) If you respect the client, understand where he is coming from and train what works, I’m sorry: you are going to get as good results as the most clinically-trained therapist. If you ignore the brain and ignore the client–and unfortunately I am well aware of professional clinician trainers who do just that all the time–then you will get bad results and end up proving to yourself that NF is indeed dangerous.

One thing about bad results, from George von Hilsheimer, who was in this field for decades longer than I: You can’t make something happen that the brain isn’t already doing. People who have headaches are likely to get headaches from NF if it pushes them a little too far or too fast. People who have seizures might have a seizure if you don’t train properly. I’m not aware of a single case where a person had a seizure as a result of NF who was not seizure prone.

Hope this helps. Especially I hope it helps keep someone who is interested in coming into our field with passion and enthusiasm from being diverted by a scare tactic. BTW, you might point out to your taxi driver that there are plenty of cases of negative effects from HEG as well. Same reasons.

Building Clientele

Maybe you could only get one per MONTH. That would produce $10,000 AFTER repaying the cost of the initial investment. That would require about 1 20-minute session per day–but really only 3 sessions a MONTH where you actually had to participate. It seems a pretty fair return.

Almost any one should be able to find one person a month! But to really help a LOT of people and earn a very nice side-income, you have to learn about marketing.

In 1994, when I was just starting Attention Development Programs in Atlanta, no insurance paid for NF. Almost no-one had ever heard of it. Yet within 2 years we had 4 offices operating, most with more than one training room. We did have a small advertisement (size of a business card) in two free parenting magazines that cost less than $200/month. It just said, “No more ADD, No more drugs.”

But marketing is not advertising. Marketing is identifying the population you want to attract, discovering what you can offer that competitors do not and letting people know about it and getting the word to people who would be interested.

What I had discovered was that there were lots of families who did not want to get a lifelong diagnosis for something that training could resolve. There were many who either resisted taking drugs–or had been down that road and discovered it led nowhere except taking more drugs for the rest of your life, with side-effects and less-than-ideal results.

“No more ADD” told them we didn’t diagnose and didn’t work with diagnoses.
“No more drugs” told them we didn’t require people to take drugs, and in fact we often helped them get off the drugs.

Just because a doctor decides that shyness is now a disease called “social anxiety disorder” doesn’t mean it is. There are many ways to improve performance in attention: drugs in the short term, training/exercise, dietary supplements, etc.

People buy thousands of dollars per year of dietary supplements (not paid for by their insurance) often over years. But you believe that they will not pay less than $1000 for something they can do in 4 months to get a lasting change. And you believe that because…I guess because people you know in the mental health field aren’t doing very well with NF. But how are they marketing their service?

HEG is not psychotherapy. HEG is not a “treatment modality” any more than exercise is. A psychologist can work with HEG, just as a physical therapist can have you do the same exercises you can do at a gym or at home. But you don’t have to pay a psychologist for HEG, nor a PT to work out in your living room.

When people called ADP and asked if we worked with ADHD, I said, “No, but we can help people pay attention and control their behavior better.” When they asked if I were a psychologist or a neurologist, I said, “No. If you want medication or diagnosis, go to an MD or a Ph.D. I’m a personal trainer for your brain. Anyone has the ability to change how his brain works by exercising it–same as any other part of the body–if they have the right tools and coaching.” Do you take health insurance, some asked, and I said, “Health insurance doesn’t take us. Insurance pays for surgery or drugs when something is broken. There is probably nothing you could do that was better for your health than to exercise regularly, but your health insurance won’t pay your monthly gym fee.”

But your sell is MUCH easier today. My one-channel EEG amp that read up to 32 Hz, my computer and monitor cost me nearly $5,000. The HEG Signature Package costs less than $2000–as little as $1500 if you wish.
We charged very little, $65 for an hour session of EEG with a trainer present the whole time. Usually 40 sessions in 6 months. I’m suggesting you charge $40 for a session, 24 sessions, 4 months.
We had clients buy a 10-sesson package, and at the end of every 10 sessions we met to determine whether or not to continue. You can charge a flat price up-front, as a gym does, of $960 and track the client’s progress on graphs and reports on the computer.

Are your colleagues who are struggling offering $40/session prices? Are they offering 20-30-minute sessions at the client’s convenience 1-3 times a week? Are they setting a termination date up front, so the client knows what to expect? What is the total cost of the service they are offering? What is involved in getting started (assessments, diagnoses, testing, etc.)? For you, nothing.

One way of getting a lot of clients is to offer a better service at a lower price and make it easy for them. The HEG program I outlined doesn’t require staff hours and involves a small one-time investment. Once you’ve accepted your third client, you’ve paid your full investment.

If I were setting up an office, I’d get a bright person who could help with scheduling, billing and phones and also could mentor LIFE clients in their first 2-3 sessions. Perhaps I would run the very first session and show them what to do, but my staff member would mentor the others.

The second step to getting a lot of clients is to FOCUS. I’m guessing your colleagues with 1-4 clients are offering to do everything for everyone. If I were setting up an office, I’d go after two groups first: Migraine sufferers (for whom nothing has worked) and older adults wanting to push back mental changes related to aging. Neither one is necessarily “sick” (though of course both have diagnoses if they want them). How would you reach them? What would convince them?

One of the great benefits of retired persons is their scheduling flexibility–ability to come 2-3 times a week during morning hours or other harder-to-schedule times. For many migraine sufferers, the same is true. Another benefit is that both groups tend to network, so a good result (or a bad one) can spread among a number of potential clients naturally at no expense to you. Well more than 50% of our clients in Atlanta (after the first 12-18 months) came by referral from prior clients. I would do free seminars at health clubs and health-food stores, take the HEG along and have people try it, explain the functions of the Prefrontal Cortex and how nIR training was almost exactly like aerobic exercise.

Too often I find clinicians complaining about the difficulty of getting clients, about getting paid, etc., but nearly always when I sit down to talk with them I find they are just tacking HEG or NF onto their usual service at their usual price (which might already be high, since they are having difficulty finding buyers for their services.) They think they need to change the insurance law, or buy expensive advertising or get a fancier Facebook page or website, but that’s rarely the problem.

Choose a population of clients you want to work with. (OK, if your choice is ADHD children, be prepared for the fact that there are probably dozens if not hundreds of competitors looking to work with that group, so the going will be rougher.) Talk to some of them. Present what you are considering offering and ask their reactions. What would turn them off about your proposal? What would be attractive in it? What would they add that you didn’t even think about? Think about the client. Think from the client’s point of view. Present him/her with information on what problems your service can help them with–specifically.

Reaching Potential Clients

Have you trained yourself? Had any improvements as a result? In my experience, a person who tries to train others who has never trained herself has a harder time convincing folks.

Focus also indicates…well…focus. Start with, perhaps, older adults. Talk with some of them and ask them what worries them about mental function as they have grown older. Listen to what they say, the words they use, and how they describe their frustrations. Use those phrases and words in your material.

Look for organizations that are popular with or focus on this population. Invite some opinion leaders to your office, talk with them about how HEG works and then let them try a session. Explain about your pricing and ask them what they like and don’t like about your approach. Ask them how you can best let folks with these concerns know about your services.

Get very clear about how you will respond to anyone who calls to learn more. Do you offer them a free session to come in and talk with you–hopefully be impressed and connect with you–and try an HEG session to make it less mysterious.

Women make most healthcare decisions, and most women go to beauty parlors with some regularity. Set up a presentation for the heads of those places in your community. Have some nice hors d’oeuvres and tell them that you recognize that they are an informal information channel trusted by many women in the community. Tell them about how LIFE can work with migraines, and how it can help with older adults. Let them try it out. Ideally have a simple business card or one-fold brochure that you can give them to take back to their places of business. Give them a pile of whatever you have.

Search on Google for Guerilla Marketing and read about it. Maybe get the book or maybe just read through some of the sites.

Coaching

I believe that the coaching aspect of the trainer’s job is among the most important (and least teachable) elements. Never saw a truly great trainer who was not a great coach!

I start every client the same way. I want, in that first session, simply to have the client have the incredible “aha” moment that comes to all of us the first time we realize, “oh my gosh! I’m actually changing what’s happening on the screen just by paying attention to it.” So I start with incredibly simple screen feedback: one bar graph and a point counter. One threshold. I hook the client up and watch for the first 30 seconds or so with him, perhaps explaining, “Whenever you get this bar down below that line, you hear a click and you score a point. During this period I let the auto threshold stabilize and then switch it to manual. I am also watching to see where the natural “bottom” of the bar’s movement is. Then I put my finger beside the screen right near the natural bottom and say, “just by paying attention to it, bring it down to here.”

Everyone is able to do it, but they can’t hold it there. I point out to them that this is exactly their problem. It’s not an inability to PAY attention (or stay quiet and relaxed, or keep the mind still, or whatever) that they are missing. It is the ability to STAY in that state. The better they get at doing that in the session, the better they will be at doing it in real life.

Coaching Tips for Getting Started

When you are training, some clients find it useful to have an idea of what state they are trying to achieve. Here’s something I like to use sometimes:

You are in a river of thoughts, currents pulling you in various directions. You find a small island, big enough to stand on. Pull yourself up onto that island. Now you are in the middle of the river of thoughts, but you are no longer subject to their currents. You can observe the currents and see what they are doing, but you are not pulled by them. All the energy you were spending just to stay in one place while you were in the water is now freed up. You are still, calm, resting but fully aware of what is passing around you. That’s a good alpha state.

Initially the island is really small and the currents are very strong, so they can keep washing parts of it away and tumbling you back into the water. But as you keep looking for islands and climbing up onto them, you find larger and more stable ones and your balance improves. Eventually you can stay on the island most of them time, aware of your thoughts but not controlled by them, and just dive into the water when you want to cool off or swim somewhere.

Orientation

It’s a common problem for trainers to get so wrapped up in the technology that they confuse not only potential clients but themselves. When you go look at a new car or a smart tv, etc., do you actually want the salesperson to tell you how it works? Probably not. You want to understand what it can do for you. So I have always tried to present it in a way that makes sense in terms the client will understand:

1. What does the client want to change? Problems of attention/focus/learning? Issues of mood? Physical functions like sleep, appetite, pain? Control–too much or too little? Performance? Any good sales person (and that’s what you are at this point in the process) starts by finding out about what the potential client wants to buy. Get them talking. Ask questions and listen. Focus your response.

2. The most important thing for clients to understand is that the brain is part of the body. Everyone understands that they can change physical performance by exercising the system that underlies it. Want to be have more energy? Train aerobically. Want to be stronger? Do weight training? Want to be more flexible and balanced? Do Yoga/Pilates/T’ai Chi. Want to change the way your brain works? Train it. Nearly anything that comes from the brain–all those issues mentioned in section 1 above–can be improved by training.

3. We all recognize that the systems in our body which process food into energy or store it for future use are very complicated. We all know that they are also quite stable over time. Eat way too much one day, fast the next day, and your weight will be pretty much the same both days. All complex systems have something called a “set-point”–or actually many potential set-points. These are places where the whole complex system is at a point where it can be stable. They can be thought of as “habits” of the body. The brain–part of the body–also has set points–energy habits that are very stable.

4. Most people who are anxious are anxious much of the time, often getting more so in a serious of stages over the years, often regardless of what is happening in their lives. It’s a habit of the way they see and think about the world. People who struggle to read and listen for detail often do it throughout their lives. Their brains are “out-of-shape” and can’t produce more energy to do that kind of task for very long. If we can help the brain move to a new energy habit–a new setpoint–we change what it can do and how well, and that change becomes as stable as the old habit has been.

5. We’re going to begin by seeing what your brain is doing now–what its habits are. A number of these “energy habits” of brains have been shown to relate to problem areas in people’s lives. We’ll see if there are patterns in your brain which are consistent with the things you want to change. Then we’ll produce a plan to help you shift your brain to new habits, more in line with what you want.

6. You will change the patterns yourself. When you train here, the computer will be showing your brain as it moves in the direction of the new pattern you want–and when it slides back toward the old one. That’s called feedback. You won’t be training your mind, what you think; you’ll be training your brain, which is the foundation of what and how you think.

7. You’ll have a plan of 5 sessions. Each time you come in, we’ll train the next session on the list. We’ll cycle through the exercises–just as you would training your body at the gym. Each one will work a part of your energy habits, and working together they can help you move the whole system very efficiently and help it stabilize in a better place for what you want today.

8. You will be doing the work. You commit to coming here 2 times a week and really focusing on the training over the next few months. If you really want to change, you’ll practice between sessions as well. I’ll guide your training and help you see the changes you are making.

9. When we finish training, you should expect that the new habits will be stable and you won’t need to keep coming back for more feedback. Your life itself will give you feedback and help you keep moving in the right direction.

10. I am a big fan of hands-on experience. I would go through this usually with whoever contacted me first, perhaps on the phone. Then I invite them to come for a sample session. I usually invite the whole family, but I always address myself in the session to the client. That’s the person I want to keep engaged. After we went through these points quickly, I ask if they’d like to see how it works. First I set the client up on LIFE, explain climbing and diving, put the dot in the center of the forehead and run a session. Often I’ll then ask the client who else’s brain he’d like to see.

Always finish by suggesting a package of 10 sessions to include an assessment/training plan and training sessions. The training won’t likely be over and certainly not stable by then. But they should be seeing some improvements and they’ll be in a better position to decide how they want to proceed. I offer a price break for prepaying the package, since it demonstrates their commitment and makes it more likely they’ll attend the sessions.

Finances

I ran a completely cash-based practice in Atlanta for 10 years with multiple offices.

We asked clients, when they had completed an orientation to NF and were considering starting training, to commit for 10 sessions, offering them a discount for prepaying. We recognized that simply starting off with an open-ended commitment of 40-60-100-?? sessions was pretty daunting. We were clear that no-one was finished in 10 sessions, more likely to be looking at 30-50, but we also said that we expected that in 10 sessions we should have a better idea of how well the training was working–and they should be seeing some kind of results.

After the first ten, we’d sit back down and review the training objectives (NOT the graphs!) and the changes that had been seen and ask them to commit to another block of 10 sessions. In this way we’d step through the process with a focus on results and with prepaid sessions.

Prepaying is critical because otherwise the client has to make a decision each time they are scheduled: “Do I have the ?$ today for this? What about that soccer practice or ballet lesson or day at the beach?” If they have paid, and you have established a clear understanding that the sessions will be charged, whether attended or not, if they are not re-scheduled for a good reason at least X hours in advance, then they are as motivated to be there as you are.

The great thing about this approach was it gave the client/funding source relatively small bites to swallow, and it forced US to do something few therapists are trained to do: focus in every session on what changes were noticed, how the training is proceeding and what’s working.

Home Training

What “credential” is required for raising a child? Clearly this is one of the most complex and demanding “professions” extant. I guess if enough mothers organized themselves and found a way to generate income from their profession, it would be inevitable that some of them would also seek to establish a credentialing organization and attempt to block those who did not meet their criteria from “practicing” in the field.

As I have often said, neurofeedback (from my point of view) is the greatest SELF regulation technology since meditation. Although it is easy to forget now–when we can learn meditation from magazine articles, tape programs, YMCA workshops, books, etc.–there were centuries in its early life when meditation was a closely held secret. Those who wished to learn it or take advantage of its benefits had to go through a “priestly class” of experts: gurus who required students make major commitments to them. In the information age, as scary as it may be to those who seek to become today’s priestly class for controlling brains, it is much harder to control these kinds of technologies.

These uncredentialed mothers have a few things to recommend them for the job: no-one is more committed to the day-to-day success of their children; no-one knows their children better and can recognize when something is happening. If they are smart enough and motivated enough to seek out information and teaching, to find those among the “professionals” who are willing to share with them and help guide their learning–rather than hiding information behind the Wizard of Oz’ curtain–I say it’s unlikely that they could ever find a professional therapist who could ever do as good a job of the day-to-day training as they can.

That doesn’t mean that I believe there is no place for pros–especially good ones! I made my living training other people and their kids for a decade (even though I don’t have the “right” credentials to do so these days). Lots of families don’t have the time or the commitment or the need to learn a whole new discipline. For them, good trainers who train what is needed, who don’t rape them financially, who care about them and their kids, who share information and give credit to the client for changes that are achieved are a godsend. Having been in the shoes of those of you who are doing that work professionally myself, I have the greatest of respect for you.

My only issue is with those who seek to convince themselves–and worse, force their convictions onto the rest of us–that only THEIR training is appropriate, that only THEIR political beliefs are reasonable and valid and that only THEIR religion will be represented in the hereafter.

I’ve said many times that I believe brain training (EEG / HEG) is the greatest SELF-regulation technology since meditation. It is the client who does the work, not the trainer. Given the tools and the support, any person who is a good coach–my main criterion for excellence in a trainer–can guide a client into that self-change process. With all due respect to Cory Hammond and others who try to bulldoze us into believing that NF is a very dangerous tool, it is only dangerous if you don’t watch the client and don’t stop when the client doesn’t like what is happening. It is only dangerous if you don’t know anything about the brain (unfortunately very frequently true of professionals who rail about the risks of NF without their own special knowledge) or can’t yourself stay very focused. There are plenty of stupid things one could do–as dumb as taking a bag of needles and trying to do acupuncture–but given the opportunity to learn a bit about what to look for and how to intervene, they are fairly easy to avoid.

Why is there a benefit to home training–especially if supported by professionals who know something about NF and who have not scared themselves away from it? First, the more people in a system you can train, the easier it is to move the system. I strongly recommend to parents who get equipment and training to work with their kids that, as perfect as their own brains might be, they might benefit at least a little by training themselves. Second, there are issues like early abuse or neglect, autism, closed head injuries and others where the benefit of doing hundreds of sessions is like building up layers and layers of finish on a battered old table made of fine wood. 300 sessions is probably not feasible in a clinician’s office, but it can be done in bursts of 30-40 with vacations between each set at home. Third, there are clients who can’t really use the 30-40 minute session model, but who could begin with 5 or 10 minutes of training a couple times a day to build up to the more intensive approach. Again, probably not workable in a professional setting. Fourth, logistics–multiple clients in a family, distance, financial issues, etc.–can make office-based training infeasible.

I absolutely agree that if a clinician scares him/herself with fears of being the first one ever to be sued for doing NF just because they can’t sit behind the client every training minute, then that person should not do home training. But I absolutely hope that many professionals will give up control a little and see if there isn’t a way to help people who are as motivated as home trainers usually are.

Criteria for Home Training

I am asked with some regularity about home-based training and how clinicians can support it, if that is of interest to them. We had a large home trainer practice in Atlanta from about 1997 on (when we started getting WaveRiders and BrainMasters), and here is what we learned from that experience. I hope it may be useful to clinicians and also to those planning to start home-based training themselves:
Client/family came in 10 sessions. Of course we were testing various protocols based on an assessment during the first five sessions, but we were also evaluating the family. People had to be “accepted” into home-based training–it wasn’t automatic.

There were two drop-dead requirements:

1. There had to be an IT (identified trainer) in the family–someone organized and motivated enough to make sure the training happened and happened as it was supposed to; and

2. The IT could not be actively at war with the client(s).

These screened out a fair number of families, and it made our program more successful, since of the early families we tried who did not fulfill these requirements, not a single one had a successful training experience!

If it looked like they could make it work, and if we were successful in finding something that produced a noticeable response, then during the last five sessions the IT actually learned and practiced doing the hook-ups and running the software (with the client’s help in most cases). By the last session or so, they were doing the whole thing themselves.

The family also had to sign a contract and negotiate a contract.

First contract was signed by all family members, stating that they understood the amp was not a toy, that what worked with one person was likely NOT to work with others, so they agreed not to use the system with anyone who had not been given a training plan.

They also negotiated a contract between the client and trainer stating that the client agreed that

1. He/she was responsible for initiating 3 training sessions a week (during agreed-upon times of day appropriate for training–not 3a.m.). This was true for young kids or adults; it wasn’t the trainer’s job to do the sessions, it was the client’s. Most used a chart that the IT initialed each time a session was done, three slots per week, which was on the refrigerator or the kid’s bedroom door or someplace where it was not easily missed.

2. If the client did three sessions and didn’t complain and worked at the training, he or she gained some kind of weekly reinforcement.

3. A training period was also defined, sometimes 12 weeks, sometimes 16. If the client fulfilled the weekly requirement for every week (unless there was a dispensation for, say, illness or vacation), he or she received an “X” (negotiated between client and parents); if he or she failed, he had to pay a “Y” (e.g. clean the garage to Dad’s satisfaction).

4. There was a way to make up a maximum of one session a week a maximum of 3 of the weeks.

Kid signed, parent signed, trainer signed.

The key is reporting. I would have the IT report after EVERY session, before 11pm on the evening of the session, either by e-mail or by voice-mail. Report stated that a session was done, what, if anything was noticed during the session and what happened afterward.

We also had clients return for a follow up at 2 weeks and 4 weeks and then as needed.

Especially in families where distance, number of trainees or complexity of problem (e.g. autistic spectrum) make in-office training unfeasible, financially or logistically, this kind of option can make a huge difference.

Insurance

When it comes to insurance, you have to be careful where you put your feet. The rule (which is sometimes followed) is: if there is a specific code for a modality, you must use it–not the more general code. There are specific codes for neurofeedback (despite the fact that it is a subset of biofeedback). You are supposed to use those, and they will be refused, at least by the great majority of insurance companies. I’ve heard a number of stories of practitioners calling the insurers of clients to find out about billing and being told to bill it as biofeedback or even bill it as individual psychotherapy. That’s fine, but if there is a complaint and an investigation, you WILL be accused of insurance fraud. The company won’t care that one of their functionaries TOLD you to do it.

Biofeedback is approved by the FDA for certain uses, but neurofeedback is not specifically mentioned because “there isn’t sufficient research showing its efficacy”. Of course no one from the FDA has looked at the research on NF in at least 20 years–if ever. Someone has to take up that standard and go to battle, marshal the research, submit it, identify the diagnoses for which NF has been shown to be effective, etc. Unfortunately, though there is no shortage of professional organizations in our field, their efforts seem to be focused more on limiting who can practice and arguing about how many angels can dance on the head of a pin rather than putting together a serious approach to FDA or insurers to change the current state of things.

As for convincing insurance companies with “scientific demonstration” that NF works with ADHD, there’s PLENTY of published evidence that NF works with ADHD and a variety of other things. What about the next 20 studies will convince insurers that did not convince them in the past 20? Or, if we wanted to believe that insurance companies make these decisions based on “scientific demonstrations”, how could we explain the fact that they happily pay for 8 year olds being given stimulants, anti-depressants AND anti-convulsants (or anti-psychotics) when there is not one single published controlled study showing the effects–or measuring the risks–of such combinations?

For those who still want to believe that neurofeedback is competing on a level playing field, read this: “In January 2003, the FDA approved Prozac for use in pediatric depression, despite only weak data for efficacy. Less than a year later, in October, the agency issued a ‘Public Health Advisory’ alerting physicians to reports of suicidal thinking and suicide attempts. A regulatory authority usually requires proof of efficacy, but in the face of an acknowledged lack of evidence, the FDA reversed the usual burden of proof, stating: ‘failure to show effectiveness in any particular study . . . is not definitive evidence that the drug is NOT effective’ (Food and Drug Administration, 2003).”

For those NFers who long to be on the inside of the medical/pharmaceutical/insurance complex, I fear the world will be a frustrating place for many years to come. For those of us who just want to show people the power they have to change their own brains, all that is just a distraction.

Neurofeedback as Technique

The reality (or at least MY reality) is that NF is a technique–not necessarily a discipline unto itself–again like meditation–so it can be accessible to many different disciplines, or to a layperson who is willing to spend the time to learn and become skilled in the technique.

To the great discomfort of some in the field, one of NF’s crucial elements is that “the client does the work”. I use the analogy with clients that I’m just the coach; you’re the player. I can try to prepare you by having you practice certain things; ideally I can help you recognize what you do well and what you don’t; I can help you set some goals (maybe even beyond what you currently think is ever possible) and teach you to track progress toward them and adjust when necessary to stay on target. Those are all things any coach would do, whether the task is winning football games or getting better grades or feeling calm and safe a greater percentage of your time. That stuff you either have or have developed–via professional preparation or life experience. But the great coach gives credit for the victory to the players–though he may take responsibility for not succeeding.

Learning to find sites, place electrodes, recognize a clean signal, define/refine a training plan, operate the software, set and adjust thresholds and frequency bands, use the feedback options effectively for individual clients: that’s technical skill and technique. I used to say, “I can teach a monkey to do that part,” though 6 years of training interested neophytes and skilled trainers half of each year, I’ve adjusted my claims on that one. I’ll say that most anyone willing to spend whatever time and effort is required on their part (a lot has to do with comfort with Windows) can learn the technique.

I also strongly believe that if I hope to be a great or successful baseball coach, it would be a lot better if I had stood in that little chalk box and tried to hit a small hard ball being thrown past me at 90 miles an hour from 60 feet away, sometimes curving at the last minute. I’m astounded to this day by people who want to train other people’s brains without ever having sat in the client’s chair. Therapists have to be therapized, chiropractors get adjustments and NF trainers should be hooking themselves up–or at least have done an assessment and trained a training plan and tracked the changes in their own lives. That would be a very good place to start: practice the skills, experience the process and come out a better person (and trainer) yourself.

All a health care professional knows about chiropractic or psychology or family systems or physical therapy or teaching may change the way you see and respond to people’s problems, but it doesn’t do a thing in terms of helping you learn this amazing technique that hangs out at the intersection of electrical engineering, psychology, computer science, EEG, coaching, family systems and learning theory. That is something all us trainers have gone through. I still do when I’m not sure if what I’m doing is really moving things as fast as I think they should.

Developmental Model

As you know, one of the main beliefs beneath my system is the belief that in brain training we are seeking to help clients to develop–not “fixing pathology”. That approach, which is repeated in every first session with every client, leaves the authority for the training in their hands, with me acting solely as a coach. Because of that approach, I don’t have problems in most cases getting people to open up with me. Those who are less forthcoming in the PBA or Performance Based (subjective) Assessment, which whenever possible is combined with assessments from others close to the client, often share more intimate material when I show them patterns in their BBA (Brain Based or Objective Assessment) and ask if they can relate to any experiences that might fit the usual correlates for those patterns.

I recently assessed a woman in her 70s who reported anxiety and depression but couldn’t think of any cause for that except that it started when her daughter had left home years before. When I showed her the huge differential in hibeta in her right temporal lobe, she started talking about the loss of her father when she was 20 in an accident on a routine business trip, the news of which had awakened her one morning. She had forgotten to mention that, but when we connected that with her childlike terror reaction whenever anyone she loved didn’t return home at the hour or on the day she expected and the fact that she woke up every morning with her mind full of thoughts of dread and fear, she could make the connection. And training down the beta and hibeta in her first session resulted in her sleeping easily that night and waking up without the negative thoughts the next morning, which certainly helped her to decide training was a worthwhile pursuit.

My reaction to your idea is, as others have said, that it skirts perilously close to a diagnostic approach–if not exactly in clinical terms. I agree that you will have a difficult time getting honest responses from participants, given the source of the request (the employer) and the professed use for the information (deciding what job one should have) and the potential use (deciding whether you should have a job at all).

Permanence of Neurofeedback Training

I usually ask how permanent the problem has been. Did the client just start to be anxious or has it been a part of him/her for years, perhaps getting worse? Most people will recognize that the problems are stable and often deteriorating.

I explain that brain activation patterns (like other setpoints in physical systems like weight) tends to be very stable over periods of time, though they can get better or worse depending on consistent changes in the inputs (what and how much you eat) and/or outputs (how and how much you exercise). The same is true with training a brain.

What you do with brain training is to give the brain information and guide it toward more efficient production and use of energy. Once the brain stabilizes with this new “habit” it becomes as stable as the old one was.

Of course there are some things we can work on that aren’t based on stable activation patterns: Parkinsons, MS, CP, Alzheimers, TBI’s, Autism, etc. which relate to serious (and often degenerative) processes or disruptions in the brain. Training those can result in positive changes, but training can’t stop a degenerative process.

I also point out that our training may be working with or against a natural process. Children’s brains naturally get faster and move toward greater use of frontal and left-hemisphere activity as they mature. So a child whose brain is behind the natural developmental curve, once training has moved him/her into the “normal” range, will not only hold the gains made in training–they usually continue to improve AFTER training. Aging, on the other hand, also follows a natural curve, but one that is heading downhill. We can push the wagon back up with training, but not long after we stop pushing, it will start rolling back down again.

Renting Equipment to Clients

It will come as no surprise to you that the homes of many of our clients are often chaotic, and although EEG equipment is solid, it is not built for rough use.

When we did a lot of home-based training in Atlanta with EEG and rented equipment, we always had to make sure there was an “identified trainer” (IT). This person had to be organized and motivated enough to make sure the sessions happened, and the IT could not be actively at war with the client. Many adults were able to be their own IT. We discussed with the IT where the equipment would be kept between sessions, who was to handle the headband, etc. We agreed on the minimum number of sessions a week (3) and generally tried to get people to commit to doing training at a regular time and figure out with them when the best time would be.

I would have the people you will rent to make a deposit reserve of $500 (the cost of either the Peanut or the headband) which you will return to them when the equipment comes back in good shape.

I would be somewhat skeptical of the level of commitment of a client who could not make 2 sessions a week. The chances are–even with a home-training setup–they won’t get many (or any) more done at home! But I suppose if paying the monthly rent for the unit doesn’t help motivate them to make the training important (15 minutes 3 times a week…then you’ll get the unit back after a month.

If you rent, make sure your price is high enough so that people will need to be motivated to decide it’s worth “taking a chance” If the entire unit costs you $1000, I would rent for $200-250 a month.

Sample Sessions

I like to start off by having the full family come to a first session I call the “sample session”. In that I focus almost exclusively on talking with the client, finding out what (or if) there are issues she would like to change: “what in your life would you like to be able to do faster, better or more easily?” I give a brief description of fast vs slow activity (from the Level 2 video) and ask the client which she thinks will be strong when we look at her brain. Then we go in and hook her up, explaining what is being done in simple terms. We look at the power spectrum. I demonstrate where the slow waves are, where the fast are, ask the client to really focus on the tallest bars and try to make them go down just by looking at them, etc. We note whether there is a lot of fast or slow activity and how that might make it more difficult for the brain to help her do what she wants to do.

I like to use the analogy: people are often told that they are dumb, or they aren’t trying, or they don’t care, when their brains are really good at making one kind of activity but can’t do the others so well. If your brain were a car, intelligence would be the horsepower of the engine; brain training works on the transmission. You can have a very powerful car, but if you only have first gear, you can’t take it out on the highway! No matter how much you want to or how hard you try.

Then I use the “sample session” brain-trainer design, which simply provides feedback on a single band (usually at Cz). With the family watching, the client demonstrates that–with or without knowing HOW–she can begin to control, for short periods of time, the target activity. We play a few rounds of pacman, and she makes it through the maze a little faster each time.

In short, the goal here is for the client to experience a) I can DO this; b) my family is impressed that I’m doing it. If there are other siblings, in the car on the way home, I want them saying, “How come SHE gets to do it, and WE don’t!?”

I always tell the client two things in that first session–and reinforce them in later ones: YOU are the only one here who is doing any work, so when you start to be able to do things you couldn’t do before, YOU get to take the credit! And I suggest, “tomorrow, when you see your friends, do something for me: tell them, ‘hey, you know what I did yesterday? I practiced changing the speed of electrical pulses in my brain!'” That usually gets a laugh, because we recognize that everyone will say, “yeah, sure!” Then I tell her, they won’t believe you, but you saw yourself actually doing it today. The more you practice this, the better you get at it, the more you will be able to do something really well that most people don’t even believe is possible! It will be a secret power that you have, and you’ll have it for the rest of your life.”

So starting someone off with a way of understanding brain training as something that is very cool and beyond most people’s ability to even imagine is an important base. Equally important, though, when you are alone with the client, you need to sit down and say, “look, I know why your parents want us to do this. I know what they want to get out of it. But how about you? It’s your life, and you’re the one who will be doing the work, so if you could imagine some changes in your abilities, in your life that would make this all worthwhile, what would they be?” Most kids can’t answer that question very easily, but you can’t take “I don’t know” or “nothing” for an answer. You have to probe, ask more detailed questions about school work, about how she feels about herself, about social life, about her hopes for the future, about free time, about whatever, until she can begin to find some things she can put “up on the wall” as objectives that SHE could get excited about.

So the bottom line is not that she suddenly realizes she is “different” and “has to” do brain training. I want her to recognize that ALL of us are different from one another. But few of us have the chance to “MAKE ourselves different in the ways WE want to change” and few of us “get the chance” to do brain training.

Finally, it’s important, in my mind, that the idea of brain training not be seen–especially by the client–as something that will be going on for hundreds of sessions. There should be some kind of target end point, and there has to be some way of measuring and demonstrating what results are happening. Without that, it’s all just a waste of time.

Showing Clients Their Assessments

I don’t show parents the TLC. I guess, if I had one of those parents who can’t believe their own experience, I would remind them that, if they took their child to a physician to deal with problems of attention or impulse control or anxiety or anger or whatever, they probably would not ask the doctor to show them changed levels of neurotransmitters in the brain as a way of “proving” that the treatment was helping or not. They probably wouldn’t even ask the doctor how he/she decided that serotonin or dopamine or norepinephrine or glutamine were the neurotransmitter involved in the “chemical imbalance” in the brain that was allegedly “causing” their child’s problems. If they don’t believe they can understand the brain at the chemical level, what makes them believe that they can understand it at an electrical level?

Ask them to give you the same benefit of the doubt they would give their doctor or therapist: You are paying me do what seems like the right thing based on the knowledge and information and experience I have. Your job is to judge the outcome by watching the things that brought you here in the first place: behavior/mood/performance. If you think you know more about the brain or about training it than I do, then you should train your child yourself–or go find another trainer who knows more than you do.

I never say that the TLC (or a population-based QEEG) is a foolproof reading of the brain. Anyone who’s done more than 2-3 of them knows that if you look at the brain when a client has just gotten over being sick or hasn’t slept well for a night or so or has just broken up with his girlfriend or just ate a Big Mac and a Big Gulp of Coke or hasn’t eaten anything in 8 hours the reading will be less than ideal. Does that mean it is inaccurate–or accurate? Why would anyone expect (unless we told them so) that a static measurement of a chaotic energy system would be anything more than a helpful guide in picking strategies? Do the general patterns in the brain remain pretty stable (reversals, hot temporals, etc.) regardless of when we do the assessment? Yes, they do. That’s why we look for general tendencies like those, and that’s why we try to find which of those gives us greatest leverage in moving the brain in a desired direction. But if you want to pay me to give you a nice EEG graph, I can do that. If you want your child to be able to pay attention better, feel less anxious or whatever–then let’s focus on THAT.

Having said all of that, I fully recognize that you will run into the engineer dad/accountant mom who believe (NEED to believe) that the universe can be reduced to numbers on a computer screen and doing things to change those numbers is what life is all about. If you fall into their game, you’ll have lots of fun trying to “prove” that what you are doing makes sense, that it is or is not working, etc. And maybe, if you’re really lucky, you’ll get a client whose numbers do appear to change in the “right” direction at the same time performance is changing. But I sure wouldn’t bet my practice on it.

Training in Schools

HEG in Brazil

HEG works the prefrontal cortex, which is heavily indicated in all issues of attention and self-control. It’s very fast and easy to do–about 20 minutes per session, doesn’t require the client’s head to be cleaned up and can be done by an aide after about 2-3 sessions of practice. I’ve got a project going in a Brazilian public school right now, training 12 kids using teachers teachers (I suggested aides or volunteers) in an 8-week program that includes evaluation of the results. Of course with public schools (especially here in Brazil) nothing ever works as planned, but we are seeing some positive early results.

Another benefit of HEG over EEG is that we pull kids out of class for 20 minutes, where you’ll need 45-60 minutes for NF training. We’ll be doing 300 training minutes in 20 sessions; with EEG you’ll be looking at 35-40 sessions. Using EEG reduces the number you can train and increases the loss of class time.

We get a grades report prior to the start of the training and another 4 weeks after the end.

Also parents and teachers are asked to complete weekly a count of number of times 10 behaviors occurred daily (they are objectively observable, e.g. fights/arguments, failure to complete assigned task in time, etc.), so we can track changes during and after the training (for 4 weeks.)

Frequency of training in schools: 3 sessions per week during the first 4 weeks, starting with 3 minutes per site (3) and increasing one minute each week.

2 sessions per week during the final 4 weeks, starting with 7 minutes/site (2 sites) and increasing one minute each week.

I’ve thought a few times that it would be cool, with some of the kids we’re working with, to be able to refer them to a 2nd level of training with EEG. Many respond well just to HEG, but I have a couple in our first group of 12 who seem to have very low IQ’s. 3 of the sets of parents are illiterate, so we had to put pictures on their tracking forms

EEG in California

Many years ago Julian Isaacs told me of a program he had done with EEG (pre-HEG days) in a California school. His goal was to simplify: not do assessments or involve tricky hookups so lay trainers could handle things easily. They did 3 trainings of 10 minutes each at T3/T4, C3/C4 and F7/F8 training down slow and fast frequencies and rewarding SMR. I think they did 30 sessions, two or three a week. The results were quite impressive working with children with attention and impulse control problems. You might look at combining HEG with something like that.

A Q-WIZ would be perfect for such a program, since you can train HEG and EEG with it without switching amps. I’ve done a few times a 3 or 4 channel bipolar like T3/T4/C3/C4/g/F7/F8/Fz/Pz, which allows you to train all of them at one time, but I haven’t done enough to say that I thought it worked better or worse than 1C.

Standardized Testing Prep

We did a program not with the GRE but with the SAT’ in Atlanta in the late 90s that was quite successful. It was more like a squash or low frequency squish, though with some more anxious clients we used a windowed squash (not called that in those days).

We did a few sessions with each client to start giving the sense of what the state was the produced scoring. Then each client began doing sample exams while hooked up and getting feedback, but the feedback was reversed: when the client was in the target focus state (about 85% of the time from the baseline), there was no sound to interrupt his focus on the exam. When he went out of focus (using fixed thresholds), a tone would sound.

One of the keys was to work with each client to develop a strategy based on his/her own brain’s capacity. For example, one young man found that he could do 2 questions consistently before he started to lose focus. He developed a strategy (by the time he took the exam he was up to 4 questions) of doing 4 questions, then closing his eyes and breathing out fully and then back in. Then he opened his eyes and did the next four problems. He had one of the most remarkable improvements in pre-post scores (sorry, I can’t recall the numbers any more), which more than made up for feeling a little silly taking his micro breaks when everyone else was pushing themselves on and on to the next question.

That program was a fixed number of sessions, and the later sessions were done in group settings (headphones, so each person heard only his/her own feedback) to introduce distractions into the process. But if you are working on an individual basis, I’d look at the assessment and see what kinds of things are getting in the way of focus and train for those.

Training Oneself

It’s always amazing to me how many people skip their own training–even assuming that everyone who is drawn to NF already has a nearly-perfect brain–and jump right into working with others. That’s like a person trying to be a professional basketball coach who has never played basketball. I’ve been training and supervising trainers for 20 years now. I’ve spent a lot of time trying to figure out what makes the great trainers I’ve worked with–maybe 8 or 10 including myself–so much better than competent trainers and what made ineffective trainers.

The great trainers all had 3 things in common:

1. Coach: they came from many different disciplines from M.D’s to moms, but most of the good ones and all of the great ones were great coaches: they didn’t categorize clients, but built upon their strengths and guided them to overcome areas of weakness. They were motivators, and they were clear with their clients who was actually doing the work and who got the credit. They didn’t worry about the client “liking” them (though their clients generally loved them–even if not ALL the time). They taught the client to set goals and meet them.

2. Computer: A person who can’t get comfortable with Windows and basic computer skills can never be a great trainer. It’s like trying to learn algebra in a foreign language. At least one of the great trainers I know started with a great deal of difficulty in this area, but she became a very practiced and skilled operator–at least in the neurofeedback software. The computer part of training doesn’t require anything very fancy, but it does require that you be comfortable doing it so you aren’t distracted from the client.

3. Client: All of the great trainers I’ve known were fascinated by their own brains, wanted to improve them. They knew what they wanted to change and started with that goal at least as a part of the larger goal of working with clients. And they stayed with it. I’ve probably done 300 sessions on myself–40 of those in my first experience training NF. I can convince people that it can help them, because it’s helped me. Another important benefit of training yourself is that you learn to be a conservative trainer. When you train yourself, you have to clearly differentiate between when you are the trainer and when you are the client. Most of the time, obviously, you have to be the client, so you begin to realize just how much the client’s brain does by itself without a doting trainer. That speeds up tremendously the process of the trainer doing less and achieving more!

Validity of Neurofeedback

As to professionals who refer to NF as pseudo-science, I would ask them for the objective scientific research showing the effects of multiple psycho-active medications on young children–or adults. If you’ll actually read through the articles “demonstrating” the efficacy of, for example, Prozac, you’ll find that the difference between the response in the medication and control groups was within the margin of error in the study. In other words NO PROOF. So why, I wonder, would such a study have been published? It’s far from being a secret that the FDA is funded by the drug companies it “oversees”. It’s far from being a secret that the “studies” that show the effectiveness of the drugs are funded by…um…drug companies. But physicians rarely actually read those articles–much less articles on things like NF. They don’t have time. They may look at the summaries or hear about them from reps from the companies. Many of them participate in “clinical trials” funded by the companies. If something was published, it must prove something, and if it was published in a medical journal, it must be reliable. The fact that nearly 100% of the advertising revenue that funds the medical journals comes from ads by drug companies doesn’t suggest any conflict of interest, does it?

As to the effectiveness and outcome studies for psychotherapy, it’s been a while since I updated myself in this area, but 10 years ago if you reviewed any of the large meta-surveys of research studies, the results were basically 1/3 get better, 1/3 get worse, 1/3 don’t change.

Granted that articles on NF have a horrible time getting looked at by the mainstream journals, but there are plenty of articles published, many are well designed, and they show the NF works as well or better than medications or other interventions. But for many “scientists”–especially those in the in-group–new evidence that conflicts with what they already believe isn’t convincing until the whole world around them has accepted it.

Galileo wrote in 1610, after he had invented the telescope and could SEE that the earth was revolving with the other planets around the sun, “what would you say of the learned here, who have steadfastly refused to cast a glance through the telescope? What shall we make of this? Shall we laugh, or shall we cry?” These were the “scientists” of the day he was speaking of. How about the neurofeedback literati who shouted Gene Peniston off the stage at a conference on NF when he tried to present his first study on alpha theta with alcoholics–his own colleagues?! Thirty years later, after he had written a book demonstrating the Copernican theory (which was withdrawn from publication shortly after its publication by the powers of the time) and after he had been judged by the top experts of the time and had to recant or face torture and execution, he finished his life blind on a small farm. I’m not sure how many hundred years later the sources of truth in that time finally admitted that he was right.

If the fact that your client, upon training to reduce demonstrated high fastwave activity in the temporal lobes, has gotten better is not convincing, then I would ask how exactly a physician decides that a medication choice is working, or a therapist that therapy is working. isn’t that based on outcome evidence?

Ah heck. Let people believe what they will. The family of your client, and the client, and those around him who are willing to look through the telescope will be happy to accept what we all know. The stuff works, it doesn’t have side-effects. It’s a lot less costly than pharmaceutical/surgical interventions and it reinforces the client’s sense of self regulation–the opposite in every way of what the religion of modern medicine accepts as dogma today.

Research

All those who bravely continue stating that if ONLY we had some really good studies showing the effectiveness of NF, THEN the medical/therapist/insurance community would finally accept the modality and embrace it must never, I guess, have read Barry Sterman’s early work on epilepsy done 40 years ago, Lubar’s multiple studies published over a period of decades. Surely, with the superb studies of Peniston and Kulkowsky, which have been reproduced, we can at least be sure that neurofeedback is the treatment of choice for alcoholism…right?

Oh, that’s right. The problem is that we don’t have “large-scale, control-group, double-blind studies” in enough volume. The gold standard in research, right? So that’s why use of multiple psychoactive medications to treat young children is the clinical/insurance approach of choice–because there are so many large-scale, control-group, double-blind studies (funded by all that drug company money) demonstrating the differential efficacy of this approach. There are…how many? Oh wait. None. As in zero. As in not one single study EVER published–ever even ATTEMPTED.

So perhaps the real problem is just that all our little outcome studies (the gold standard for many clinical fields) or ABA Crossover studies (also a gold standard, since it demonstrates an effect in both directions) just weren’t published in the right journals. I know deep in my heart that JAMA is just waiting–peer reviewers holding their breath to finally get that truly great neurofeedback study that meets their standards so they can rush it into print. We all know that politics and disciplinary prejudices have absolutely nothing to do with what gets published where.

So while our more “scientific” brethren are holding their breath, waiting for the truly watershed study that will finally slip the blinders off the collegial world of mental health, let me remind the rest of you that even in the highly scientific MD-dominated, heavily-funded world of psychopharmacology, the “decision tree” doesn’t seem to exist to any very useful degree. If you have ever had a loved one who went the medical route for help with anxiety or depression or attention problems, you have likely discovered that it has a very disconcerting “trial-and-error” feel to it. You try this drug…get no result. Try another…bad side-effects. Try another–ah, that seems to help…but still we haven’t dealt with X or Y. So we add another drug, then another, then perhaps something to help deal with the side-effects.

In my own experience (which granted does not have a scientific and surely not a clinical education behind it), I am stuck with pure practical results-driven ways of looking at the problems brought to me. I have been forced to recognize that what works great with one client who has a very supportive family might not make a dent in another client whose family is broken, dysfunctional and primarily negatively focused. What helps one person with “generalized anxiety disorder” may actually make another client with the exact same diagnosis worse. But I believe, again based on my own paltry unpublished experience, that if I look at the brain and the client’s subjective presentation and do so in the light of the relationships between symptom constellations and activation patterns which have been demonstrated by QEEG research, I am often able, by testing the options, to find something quite quickly that works well and moves the client in the desired direction.

For those who are not necessarily willing to spend the time to learn about sub-cortical drivers and EEG patterns or don’t have hardware or software that allow them to actually look at the brain in any kind of detail, a generalized decision tree may make a lot of sense. I prefer the client-specific “decision tree” that I call a training plan.

I like to ask a few questions when I am confronted by someone singing the research song: Which studies have you read and what, methodologically, do you find disagreeable (I mean more than any research publication, since they seem to exist primarily for other researchers to pick holes it.)? I have not yet run into anyone who has actually READ a study. When they have to admit that, then I can say, “Oh, I see. So you are simply passing on unfounded gossip, then.”

There is an excellent survey article by Joel Lubar, “Discourse…” published in around 1989 or 1990 I believe. The January 2000 issue of Electroencephalography is dedicated entirely to a review of the literature on NF in a variety of fields, edited and forewarded by the chief of Neurology at Harvard Medical School. ISNR has an excellent bibliography in a variety of areas related to neurofeedback, efficacy, comparison with stimulant medications, etc. Barry Sterman’s published research from the middle 70s and beyond is very hard to argue with. The Peniston and Kulkowsky studies are beautifully done and very powerful.

Neurofeedback vs Other Research

I presume your friend’s also disappointed by the lack of double-blind studies on the use of two or more psychoactive medications with patients taking meds for depression, attention problems, anxiety, etc. How about the lack of double-blind studies on the use of anti-depressant drugs with children with attention problems. I personally am very disappointed at the number of surgeries that are done in the Unites States and around the world for all manner of problems, without one single double-blind study showing effectiveness. Ask your friend how much of a difference there was in the Prozac studies that got it FDA approval between the treatment group and the control group. (Not much). Ask how many trials had to be done in order to get one that showed that difference. (At least several).

I’d actually love to know how many of the double-blind studies done on whatever issue of importance to her your friend has actually read. It sounds like she’s been reading websites, where this is one of the favorite mantras of pharmaceutical apologists. It’s quite easy to do a double-blind study with a pill, since it’s very easy to put active ingredients in one pill and none in another, and no one can tell the difference. So the client doesn’t know and the observer doesn’t know who is actually getting the real pill. But it’s a little harder to do fake surgery–or even fake neurofeedback–that won’t have any effect whatsoever.

Sham Neurofeedback

The idea of doing “sham” NF is one that has always intrigued me, since I’ve had probably 50 kids in my career tell me that I wasn’t really training their brains (when I KNEW I was) within a minute or so of the beginning of a session–only to find that I had left the software in playback mode instead of capturing EEG. Looked fine to me, but it didn’t fool them at all. It’s likely that eventually even adults would be able to figure out that what was happening on the screen wasn’t related to what their brains were doing. Of course you could train something other than what you thought would work, but how would you argue that this wrong training had no effect?

You might read some of the early Lubar/Shouse studies or Barry Sterman’s work on epilepsy. Nope, they weren’t double-blind. They were a more powerful research demonstration called A-B-A crossover studies. Lubar trained a client with high theta/beta ratios to reduce theta relative to beta for “x” number of sessions, and an observer in the classroom tracked out-of-seat and off-task behavior, inability to respond to questions and other measurable items. Then, without telling anyone (client or observer), he reversed the protocol, training the client to INCREASE theta relative to beta. (That was the “B” part of A/B/A). Then, after a while, he again reversed the protocol back to the original training down theta relative to beta without telling anyone. What happened? The client(s)–this was repeated several times in several case studies–improved with the first A in measurable ways. More importantly, they got much worse during the B phase. And then they got better again when trained back to A. In other words there was a direct correlation between the training effect and the measured outcomes. Sterman also used this approach but ended up terminating it when, during the B phase, he was causing participants to increase seizure rates and severity and decided it wasn’t worth it to get the article.

That’s why almost all NF research, like research on surgery and most other interventions that don’t involve pills, is outcome studies. You take a number of clients (matched to a control group of the same age, sex, socio-economic and intelligence characteristics) and run one group through an intervention, measuring the pre/post outcome difference. Of course this means you are likely to have some people in the treatment group who don’t respond. You’re not allowed just to select the ones who do respond–or even to select only the ones who actually finish the study. If you can show large average measurable changes in behavior or performance of the people in the treatment group that don’t happen in the other group, it’s a pretty good indication that the intervention was the likely cause.

Of course it would be great if everything could be tested by double-blind studies. Then we’d never have to worry about the serious negative effects of drugs like Ritalin only being discovered years after it had been sold to tens or hundreds of thousands of kids, because the study would have shown…oops. Ritalin WAS tested with a double-blind gold-standard study.

Validity of Results

“I generally liked your approach yet had little idea how valid any results I was getting.”? I may be handicapped by my training in business rather than clinical fields, but if I’m getting results, I consider them “valid”. I judge those based on outcomes.

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